The state of diversity in the health professions a century after Flexner

Residency Wellness: A Historical Narrative Review

INTRODUCTION

The structure of medical residency in the United States has experienced significant changes, paralleling advances in medical science and education. While these changes have enhanced medical training, they have introduced challenges, particularly in resident wellness. The well-being of residents is critical for patient care and the healthcare system. This review aims to provide an overview of the historical trends in medical residency, focusing on the evolution of resident wellness and its associated challenges.

METHODS

A narrative review was conducted, examining the evolution and challenges of medical residency with an emphasis on resident wellness. An exhaustive literature search on January 25, 2024 was conducted across PubMed, Web of Science, and Google Scholar. The search utilized keywords related to medical residency, wellness, and educational reforms. Articles were selected based on relevance and robust evidence, and information was organized into thematic categories for narrative synthesis.

RESULTS

The search yielded 57 publications that met the inclusion criteria. Historical trends revealed a shift from an apprenticeship model to formalized training programs, with each phase bringing unique challenges to resident wellness. The Flexner Report's influence on standardizing medical education, the rise of modern residency programs, and the recognition of burnout as a significant issue were key developments. Policy changes, technological impacts, and the COVID-19 pandemic have further shaped residency training and wellness. Studies highlight the need for interventions addressing burnout and promoting wellness, with varied approaches across specialties and institutions.

CONCLUSION

Residency burnout has been a growing concern since the 1970s, exacerbated by advancements in medicine, technology, and recent global events like the COVID-19 pandemic. Although awareness has increased, the need remains to address burnout and promote wellness during residency. Further research is warranted to develop effective interventions and adapt training to meet the evolving needs of residents.

Racial Disparities in Surgical Oncologic Research Funding and Impact on Diverse Populations

Racial disparities in surgical oncology research funding significantly impact minority researchers and diverse populations. This review explores historical factors contributing to the underrepresentation of minorities in academic medicine. Strategies for addressing these disparities include enhancing diversity in the physician workforce and improving funding opportunities for minority researchers, with the goal of improving patient outcomes and reducing cancer care disparities.

Trainees as Agents of Change: A Theory-Informed Model for Trainee-Driven Curricular Advocacy in Medical Education

ABSTRACT

Trainees (medical students, residents, and fellows) are beginning to make strides in pushing for changes to their education. While there are many examples of successful trainee-led curriculum reform efforts, the path to success remains unclear. To better understand the process of trainee-driven curricular advocacy, the author analyzes this process through the lens of ecological systems theory (EST) not only to provide readers with context for the barriers and facilitators to trainee-driven curricular advocacy but also to further medical education's understanding of the sociopolitical forces influencing the process of trainee-driven curricular advocacy and reform through the lens of the trainee. EST explains how individuals are influenced by a complex web of social and environmental forces. The theory outlines 5 ecological systems of influence: the microsystem, mesosystem, exosystem, macrosystem, and chronosystem. Using EST to explore the process of trainee-driven curricular advocacy therefore clarifies the many layers of influence that trainees must navigate while advocating for curriculum change. The author then draws on this theory and their own experience as a medical student advocating for local and national curriculum reform to develop a model to facilitate trainee-driven curricular advocacy in medical education. The proposed model outlines concrete steps trainees can take while going through the process of curricular advocacy both within their own institutions and on a national level. Through developing this model, the author hopes not only to empower trainees to become agents of change in medical education but also to encourage faculty members and administrators within health professional training programs to support trainees in these efforts.

Impact of Racism on the Diversification of the Pediatric Workforce

This narrative review examines the impact of racism in academic pediatrics. We begin with our challenges in diversifying the pediatric physician workforce and the downstream impact of selection and recruitment practices compounded by disparities in resident dismissal rates. We present best practices in recruitment and resources from academic societies and institutions, including examples of successful holistic review processes. We then shift our focus to the effect of racism on the clinical learning environment and the use of race in curricular materials, clinical research reports, and practice guidelines. We discuss the need to create new guidelines for the inclusion of race in teaching materials and strategies to teach residents to critically interrogate clinical practice guidelines. Ultimately, we examine how racism impacts retention for faculty. We present the demographics of underrepresented in medicine faculty, the impact of racism in the work environment on attrition and mentorship, and where national programs are working to fill the gaps.

Contributions and Legacies of Selected Black Pioneers in Ophthalmology and Institutional Milestones

PURPOSE

Establishing a record of key contributions of early Black ophthalmologists can help illuminate future generations. We aimed to identify major physician pioneers in ophthalmology, delineate their contributions, and place their ascendance in a historical context to understand the institutional and cultural barriers they overcame to achieve success.

METHODS

PubMed and other databases were searched, along with death notices and archeological records, using "Black," "African American," "eye surgeon," "Negro," "Journal of the National Medical Association" and other search terms. Librarians from the Library of Congress, National Institutes of Health, and key ophthalmology training institutions were consulted, as were the American Academy of Ophthalmology and American Board of Ophthalmology. Family members and colleagues of selected deceased pioneers were interviewed.

RESULTS

Many early pioneers emerged from historically Black institutions, as Black students and practitioners were then typically excluded elsewhere. Mentorship is a key theme that emerged in the careers of many pioneers and the Black ophthalmologists they trained.

CONCLUSIONS

Black ophthalmologists have contributed tremendously to eye-care practice, education, and innovation. Efforts to recruit and train Black ophthalmologists should include highlighting the roles of Black pioneers, increasing educational and training access for the underrepresented in medicine at the institutional level, and expanding pathway and mentorship programs.

Examining How Black Women Medical Students Rate Their Experiences with Medical School Mistreatment on the Aamc Graduate Questionnaire

Introduction

Few researchers have examined how medical student mistreatment varies by race/ethnicity and gender, specifically highlighting Black women's experiences. Moreover, researchers often fail to use theoretical frameworks when examining the experiences of minoritized populations. The purpose of this study was to examine the frequency of mistreatment US Black women medical students experience and how this compared to other students underrepresented in medicine (URiM) using intersectionality as a theoretical framework.

Methods

We used the Association of American Medical Colleges Graduate Questionnaire (GQ) as the data source for examining descriptive statistics and frequencies. We examined differences between US Black women (N = 2,537) and other URiM students (N = 7,863) with Mann-Whitney U tests.

Results

The results from this study highlighted that most Black women medical students did not experience mistreatment, yet a higher proportion of these trainees reported experiencing gendered (χ2(1) = 28.59, p < .01) and racially/ethnically (χ2(1) = 2935.15, p < .01) offensive remarks at higher frequency than their URiM counterparts. We also found US Black women medical students infrequently (27.3%) reported mistreatment from a lack of confidence for advocacy on their behalf, fear of reprisal, and seeing the incident as insignificant.

Discussion

A paucity of research exists on Black women medical students and even less using relevant theoretical frameworks such as intersectionality. Failure to extract Black women's experiences exacerbates alienation, invisibility, and inappropriate attention to their mistreatment.

Improving Graduate Medical Education by Aggregating Data Across the Medical Education Continuum

ABSTRACT

Meaningful improvements to graduate medical education (GME) have been achieved in recent decades, yet many GME improvement pilots have been small trials without rigorous outcome measures and with limited generalizability. Thus, lack of access to large-scale data is a key barrier to generating empiric evidence to improve GME. In this article, the authors examine the potential of a national GME data infrastructure to improve GME, review the output of 2 national workshops on this topic, and propose a path toward achieving this goal.The authors envision a future where medical education is shaped by evidence from rigorous research powered by comprehensive, multi-institutional data. To achieve this goal, premedical education, undergraduate medical education, GME, and practicing physician data must be collected using a common data dictionary and standards and longitudinally linked using unique individual identifiers. The envisioned data infrastructure could provide a foundation for evidence-based decisions across all aspects of GME and help optimize the education of individual residents.Two workshops hosted by the National Academies of Sciences, Engineering, and Medicine Board on Health Care Services explored the prospect of better using GME data to improve education and its outcomes. There was broad consensus about the potential value of a longitudinal data infrastructure to improve GME. Significant obstacles were also noted.Suggested next steps outlined by the authors include producing a more complete inventory of data already being collected and managed by key medical education leadership organizations, pursuing a grass-roots data sharing pilot among GME-sponsoring institutions, and formulating the technical and governance frameworks needed to aggregate data across organizations.The power and potential of big data is evident across many disciplines, and the authors believe that harnessing the power of big data in GME is the best next step toward advancing evidence-based physician education.

Mitigating the Isolation of Minoritized Faculty in Academic Medicine

Increasing numbers of faculty who are underrepresented in medicine has been a focus of academic health systems. Understanding the experiences of these faculty helps in creating environments that are inclusive and supportive, promoting faculty success. When compared with non-minoritized faculty, minoritized faculty face racism, isolation, diversity efforts disparities, clinical efforts disparities, lack of faculty development, and promotion disparities. While there have been contributions to the literature to better characterize disparities faced by minoritized faculty, little has been written about isolation. Isolation occurs when faculty underrepresented in medicine do not feel like part of the department or institution. They may feel excluded from mainstream culture as if they are invisible. They may be excluded from conversations, group chats, get togethers, or other work-related or social functions. These feelings can manifest as imposter syndrome and impact work performance and decision-making. In this article, the author shares how to recognize and mitigate isolation to promote an inclusive environment for all faculty.

Diversity in MD-PhD Programs and Factors Affecting Admission and Completion Among Minoritized Groups: A Scoping Review

PURPOSE

To improve awareness of diversity in MD-PhD program applicants, matriculants, and graduates; facilitators and barriers to matriculation and/or completion among minoritized groups; and the effects of research experience programs on admissions processes aimed to increase representation of minoritized groups in MD-PhD programs.

METHOD

The authors conducted a scoping review, searching EMBASE, MEDLINE, PsycINFO, CINAHL, and Web of Science through December 21, 2021, for studies that contained data on the characteristics of MD-PhD learners and initiatives aimed to make the clinician-scientist trainee population more diverse. They excluded studies that had no primary data, were unavailable in English, and were not peer-reviewed.

RESULTS

Of 4,369 articles identified, 16 met inclusion criteria. Studies conceptualized diversity inconsistently, including as sex/gender disparities (n = 11), race/ethnicity underrepresentation (n = 9), disability (n = 2), first-generation student (n = 1), visible minority (n = 1), Indigenous population (n = 1), and economic/social disadvantage (n = 1). Potential barriers to entering or continuing in an MD-PhD program among women and underrepresented ethnic minorities included the long program duration and lack of mentorship; potential facilitators included the flexibility of the dual-degree program. Limited data on high school, undergraduate, and postbaccalaureate research experience programs targeting underrepresented minorities suggest that they may help facilitate admission into MD-PhD programs.

CONCLUSIONS

The findings of this scoping review suggest that the diversity of MD-PhD students has been conceptualized in unitary, inconsistent terms, without addressing how different dimensions of diversity may intersect and impact MD-PhD admissions. Future studies should be explicit and intentional in defining "diversity" as it relates to their research questions, explore the impact of intersectionality, and systematically identify and address causal facilitators and barriers of entry to and completion of MD-PhD programs among minoritized groups.

Diversity, Equity, and Inclusion: A Decade of Progress?

The concepts of diversity, equity, and inclusion are fundamental and more recently heavily discussed within medicine, research, and the larger society. There is increasing awareness that diversity of thoughts, perspectives, and backgrounds yields stronger teams and more effective results. There is also increasing awareness that stark inequities from systemic, institutional, and individual levels exist that limit the baseline opportunities for many populations. To close disparity gaps, broad aspects of diversity and promoting equity are required and efforts must be inclusive of those most marginalized. In this Clinical Commentary, we discuss, "How and If progress has been made in Diversity, Equity, Inclusion within the field of Allergy/Asthma/Immunology in the past decade?" We discuss the current state of clinical practice and what has been revealed over the past 10 years; describe our current workforce and what progress has or has not occurred there; and finally, review the state of scientific and medical research.

Addressing challenges faced by underrepresented biomedical investigators and efforts to address them: An NHLBI-PRIDE perspective

Junior investigators from groups underrepresented in the biomedical workforce confront challenges as they navigate the ranks of academic research careers. Biochemical research needs the participation of these researchers to adequately tackle critical research priorities such as cardiovascular health disparities and health inequities. We explore the inadequate representation of underrepresented minority investigators and the historical role of systemic racism in impacting their poor career progression. We highlight challenges these investigators face, and opportunities to address these barriers are identified. Ensuring adequate recruitment and promotion of underrepresented biomedical researchers fosters inclusive excellence and augments efforts to address health inequities. The Programs to Increase Diversity among Individuals Engaged in Health-Related Research (PRIDE), funded by the National Heart, Lung, and Blood Institute (NHLBI), is a pilot program by the National Institutes of Health (NIH) that aims to address these challenges yet, only a limited number of URM can be accepted to PRIDE programs. Hence the need for additional funding for more PRIDE or PRIDE-like programs. Here we aim to examine the challenges underrepresented minority biomedical investigators face and describe ongoing initiatives to increase URM in biomedical research using the NHLBI-PRIDE program as a focus point.

Towards a common lexicon for equity, diversity, and inclusion work in academic medicine

Differential rewarding of work and experience has been a longtime feature of academic medicine, resulting in a series of academic disparities. These disparities have been collectively called a cultural or minority "tax," and, when considered beyond academic medicine, exist across all departments, colleges, and schools of institutions of higher learning-from health sciences to disciplines located on university campuses outside of medicine and health. A shared language can provide opportunities for those who champion this work to pool resources for larger impacts across the institution. This article aims to catalog the terms used across academic medicine disciplines to establish a common language describing the inequities experienced by Black, Latinx, American Indian/Alaska Native and Native Hawaiian/Other Pacific Islander, Women, and other underrepresented people as well as queer, disabled, and other historically marginalized or excluded groups. These ideas are specific to academic medicine in the United States, although many can be used in academic medicine in other countries. The terms were selected by a team of experts in equity, diversity, and inclusion, (EDI) who are considered national thought leaders in EDI and collectively have over 100 years of scholarship and experience in this area.

Racism, structural racism, and the American Association for Anatomy: Initial report from a task force

In 2021, the American Association for Anatomy (AAA) Board of Directors appointed a Task Force on Structural Racism to understand how the laws, rules, and practices in which the Association formed, developed and continues to exist affect membership and participation. This commentary is the first public report from the Task Force. We focus on African Americans with some comments on Jews and women, noting that all marginalized groups deserve study. Through much of its 130 year history, some members were an essential part of perpetuating racist ideas, the Association largely ignored racism and had some practices that prevented participation. The Task Force concluded that individual and structural racism within the AAA, combined with the broader social context in which the Association developed, contributed to the current underrepresentation of African Americans who constitute 4.1% of the membership even though 13.4% of the U.S. population is Black. Intentional efforts within the AAA to reckon with racism and other forms of bias have only begun in the last 10-20 years. These actions have led to more diverse leadership within the Association, and it is hoped that these changes will positively affect the recruitment and retention of marginalized people to science in general and anatomy in particular. The Task Force recommends that the AAA Board issue a statement of responsibility to acknowledge its history. Furthermore, the Task Force advocates that the Board commit to (a) sustaining ongoing projects to improve diversity, equity, and inclusion and (b) dedicating additional resources to facilitate novel initiatives.

The do's, don'ts and don't knows of redressing differential attainment related to race/ethnicity in medical schools

INTRODUCTION

Systematic and structural inequities in power and privilege create differential attainment whereby differences in average levels of performance are observed between students from different socio-demographic groups. This paper reviews the international evidence on differential attainment related to ethnicity/race in medical school, drawing together the key messages from research to date to provide guidance for educators to operationalize and enact change and identify areas for further research.

METHODS

Authors first identified areas of conceptual importance within differential attainment (learning, assessment, and systems/institutional factors) which were then the focus of a targeted review of the literature on differential attainment related to ethnicity/race in medical education and, where available and relevant, literature from higher education more generally. Each author then conducted a review of the literature and proposed guidelines based on their experience and research literature. The guidelines were iteratively reviewed and refined between all authors until we reached consensus on the Do's, Don'ts and Don't Knows.

RESULTS

We present 13 guidelines with a summary of the research evidence for each. Guidelines address assessment practices (assessment design, assessment formats, use of assessments and post-hoc analysis) and educational systems and cultures (student experience, learning environment, faculty diversity and diversity practices).

CONCLUSIONS

Differential attainment related to ethnicity/race is a complex, systemic problem reflective of unequal norms and practices within broader society and evident throughout assessment practices, the learning environment and student experiences at medical school. Currently, the strongest empirical evidence is around assessment processes themselves. There is emerging evidence of minoritized students facing discrimination and having different learning experiences in medical school, but more studies are needed. There is a pressing need for research on how to effectively redress systemic issues within our medical schools, particularly related to inequity in teaching and learning.

While You Don’t See Color, I See Bias: Identifying Barriers in Access to Graduate Medical Education Training

There is a need to acknowledge and address issues of implicit and explicit bias within medical education. These biases can impact standardized test questions and scores, evaluations of clinical performance, and subsequent letters of recommendation, all of which can affect the selection of diverse candidates advancing through medical training. Biased behavior toward trainees can negatively impact their learning environment and career trajectory. This article outlines key definitions related to bias and discusses the ways in which bias potentially impacts selection and entry into Pulmonary and Critical Care Medicine fellowship training. Finally, we will describe some ways to mitigate bias within the fellowship selection process and training programs.

Academic Medicine's Journey Toward Racial Equity Must Be Grounded in History: Recommendations for Becoming an Antiracist Academic Medical Center

The harsh realities of racial inequities related to COVID-19 and civil unrest following police killings of unarmed Black men and women in the United States in 2020 heightened awareness of racial injustices around the world. Racism is deeply embedded in academic medicine, yet the nobility of medicine and nursing has helped health care professionals distance themselves from racism. Vanderbilt University Medical Center (VUMC), like many U.S. academic medical centers, affirmed its commitment to racial equity in summer 2020. A Racial Equity Task Force was charged with identifying barriers to achieving racial equity at the medical center and medical school and recommending key actions to rectify long-standing racial inequities. The task force, composed of students, staff, and faculty, produced more than 60 recommendations, and its work brought to light critical areas that need to be addressed in academic medicine broadly. To dismantle structural racism, academic medicine must: (1) confront medicine's racist past, which has embedded racial inequities in the U.S. health care system; (2) develop and require health care professionals to possess core competencies in the health impacts of structural racism; (3) recognize race as a sociocultural and political construct, and commit to debiologizing its use; (4) invest in benefits and resources for health care workers in lower-paid roles, in which racial and ethnic minorities are often overrepresented; and (5) commit to antiracism at all levels, including changing institutional policies, starting at the executive leadership level with a vision, metrics, and accountability.

Inclusion and equity: Experiences of underrepresented in medicine physicians throughout the medical education continuum

The mission of pediatric medical education is to train the workforce who will provide and innovate child healthcare, including addressing healthcare inequities for children and adolescents of color. A diverse physician workforce is associated with more equitable outcomes. Therefore, it is imperative that our workforce continue to reflect the ever-growing diverse nature of our society. While diversity has been at the forefront of conversations for increasing the number of underrepresented communities in medicine, inclusion and equity are oftentimes overlooked. It is crucial to recognize that while diversity is an important aspect to the UIM experience, the overall impact of diversity is diluted when it is not paired with inclusion and equity. Therefore, the purpose of this paper is to illustrate the experiences that shape inclusion and equity for UIM physicians along the training continuum and how negative factors may impact the wellness and career longevity of UIM physicians. Our study explored the experiences of UIM physicians throughout their medical education through the lens of inclusion and equity by exploring three common factors: social support, racism and discrimination, and well-being and burnout. There may be a perception that stressors, including racial discrimination, diminish with progression through one's educational career; however, this review suggests that these stressors manifest differently relative to the trials inherent to each career stage. By exploring the interplay between these factors and the UIM experience as a continuum, we are better able to discuss effective solutions to diversity, equity and inclusion for UIM physicians.

Addressing the Need for Ethnic and Racial Diversity in the Pipeline for Pharmacy Faculty

Objective To analyze the ethnic and racial diversity of faculty in pharmacy, medicine, and dentistry in the United States and suggest how the pipeline for pharmacy academe can be diversified.Methods A retrospective analysis of the representativeness of faculty at schools and colleges of pharmacy was compared to that in schools and colleges of medicine and dentistry. The range of ethnic and racial diversity across top schools of pharmacy, historically black colleges and universities (HBCUs), and newer schools of pharmacy was evaluated for both faculty and students for the year 2019-2020. The ethnic and racial diversity in residency and fellowship programs along with graduation rates provided insight into the available pipeline for future pharmacy faculty.Results Faculty in pharmacy, medicine, and dentistry demonstrated similarly low representation of underrepresented minorities (URMs) compared to their composition within the US population. Dentistry had the largest percentage of URMs (13.9%), compared with 8.5% in pharmacy and 7.1% in medicine. Five HBCUs contributed 32.8% of all Black faculty, yet their graduates had comparatively low residency match rates. The ratio of URM students to non-URM students in post-PharmD and graduate training programs is lower than the ratio of URM students to non-URM students in pharmacy programs.Conclusion Lack of access to postgraduate residency or fellowship training programs is a major barrier to progression to pharmacy academe and impacts URMs more significantly. Barriers to advanced training must be removed or decreased to create the needed diverse faculty candidates for pharmacy academe. Without intervention, students in pharmacy programs will be primarily trained by non-URM faculty, which may impact how graduates provide care in an increasingly diverse patient population.

Trends in Diversity Related to Gender and Race in the Surgical Specialties and Subspecialties Inclusive of Oral and Maxillofacial Surgery

Medical training in the United States has undergone multiple evolutions and maturations. The Flexner Report and its effects, written in 1910, still has significant impact on modern professional education in the medical and dental arenas. The National Academy of Medicine (Institute of Medicine) in 2003 documented the need for diversity in the health care workforce, and the Association of American Medical Colleges additionally looked at Medical Education and health care through the lens of Academic Medicine. Both these reports reflected that health care institutions, providers, educators, students, and surgical residents are mandated to improve the health of the nation.

Expanding innovation from undergraduate to graduate medical education: A path of continuous professional development

A hundred years after the Flexner report laid the foundation for modern medical education, a number of authors commemorated the occasion by commenting on how the medical education system had to change once more to serve 21st century patients. Experts called for standardized outcomes and individualized learner pathways, integration of material across traditional areas, attention to an environment of inquiry, and professional identity formation. The medical education community responded and much has been achieved in the last decade, but much work remains to be done. In this paper we outline how the American Medical Association Accelerating Change in Medical Education Consortium, launched in 2013 through significant funding of transformation projects in undergraduate medical education, expanded its work into graduate medical education, and we look to the future of innovation in medical education.

Addressing the gate blocking of minority faculty

There have been ongoing efforts to increase the presence of underrepresented minorities in medicine (URMM), including faculty development initiatives, mentoring programs and outreach efforts. However, URMM faculty face unique challenges that are crucial for academic institutions and leaders to recognize in order to improve retention of this group and allow for meaningful advancement in the field. This paper introduces the concept of gate blocking, defined as what happens to minority faculty as a result of the consequences of the minority tax and systems designed to advantage some and disadvantage others. In addition to defining gate blocking, the authors make recommendations to address this concern in academic medicine and promote the advancement and retention of URMM faculty.

Mentoring as a Buffer for the Syndemic Impact of Racism and COVID-19 among Diverse Faculty within Academic Medicine

Within this article, we explore the dual impact of two pandemics, racism and COVID-19, on the career and psychological well-being of diverse faculty within academic medicine. First, we present a discussion of the history of racism in academic medicine and the intensification of racial disparities due to the COVID-19 pandemic. As a result of the syndemic of racism and COVID-19, the outlook for the recruitment, retention, and advancement of diverse faculty and leaders within academic medicine is at risk. While mentoring is known to have benefits for career and personal development, we focus on the unique and often unacknowledged role that mentoring can play as a buffer for women and people of color, especially when working in institutions that lack diversity and are now struggling with the syndemic of racism and COVID-19. We also discuss the implications of acknowledging mentoring as a buffer for future leadership development, research, and programs within academic medicine and health professions.

Social Justice as a Tool to Eliminate Inequities in Kidney Disease

Kidney disease has disparate effects on racial and ethnic minority groups, who have higher rates of chronic kidney disease and generally poorer outcomes. These disparate rates and outcomes have been attributed to social determinants of health; however, these social determinants of health are related to governmental and societal structural barriers that have created inequities not only in kidney disease, but also in other chronic diseases and in maternal/fetal health outcomes. The societal barriers to health equity include income inequality, inadequate education, environmental injustice, mass incarceration, and the enduring effects of the legacy of slavery. The approach to reducing disparities in kidney outcomes must be viewed through the lens of social justice to address these societal barriers.

The Diversity Efforts Disparity in Academic Medicine

The diversity efforts disparity in academic medicine can be defined as part of the minority tax that negatively impacts faculty who are underrepresented in medicine. This disparity can be defined as differences between minority and non-minority faculty in their recruitment or assignment by the institution to address diversity issues, climate concerns and conflict around inclusion in academic medicine. It can manifest as disproportionate committee service, being asked to be the face of diversity for the school on websites or brochures or being asked to serve on diversity task forces or initiatives. In this article, the author further characterizes the diversity efforts disparity and provides recommendations for how to identify and address it in academic medicine.

Increasing the Number of Black Otolaryngologists

Otolaryngology continues to have one of the lowest percentages of black physicians of any surgical specialty, a number than has not improved in recent years. The history of exclusion of black students in medical education as well as ongoing bias affecting examination scores, clerkship grades and evaluations, and honors society acceptance of black students may factor into the disproportionately low number of black otolaryngology residents. In order to increase the number of black physicians in otolaryngology, intentional steps must be taken to actively recruit, mentor, and train black physicians specializing in otolaryngology.

Focusing on Diversity: A Regional Internal Medicine Residency Viewpoint on Underrepresented Minority Support, Retention, and Mentoring

BACKGROUND

While the overall percentage of residents who withdraw (2.7%) or take extended leave (1.0%) are low, subgroup analysis has found that minority physicians are approximately 30% more likely to withdraw from residency than their white counterparts and 8 times more likely to take extended leave of absence. With ongoing national efforts to support diversity in medical education through increased recruitment of underrepresented in medicine (UiM) students to residency programs, there is paucity of data identifying specific experiences challenging or contributing to their overall resiliency. Better understanding of the lived experience of UiM residents will allow residency programs to create successful curricular programing and support structures for residents to thrive.

OBJECTIVE

We sought to understand UiM internal medicine residents' experiences during residency training.

METHODS

We used a retrospective review of focus group transcripts of UiM internal medicine residents from 5 academic institutions in 2017 (4 in North Carolina and 1 in Georgia).

RESULTS

Of 100 self-identified UiM residents from 5 institutions, 59 participated in the focus groups. Using a consensus-based review of transcripts, 25 distinct codes in 8 parent code categories were determined. Two primary themes emerged: resilience and isolation. Three secondary themes-social support, mentorship, and external expectations and/or biases-served as mediators for the primary themes.

CONCLUSIONS

UiM residents who became or were already resilient commonly experienced isolation at some time in their medical career, specifically during residency. Moreover, they could be influenced and positively or negatively affected by social support, mentorship, and external expectations and biases.

Promoting cultural diversity and inclusion in undergraduate primary care education

In this article, we review key factors in promoting a culturally diverse and inclusive learning environment for all undergraduate medical students, and the role of primary care educators in preparing students to work with diverse teams, patients and communities. These factors include approaches to curriculum and assessment, student community, faculty development and recruitment, and wider institutional factors. By highlighting these, including areas where further research, evaluation and consensus are needed, we hope to support further discourse on how primary care educators can promote culturally diverse and inclusive undergraduate medical education.

Mission matters: Association between a medical school's mission and minority student representation

Increasing enrollment of students who are underrepresented in medicine has been a priority of United States (US) medical schools. The authors sought to compare how increasing minority student representation factors into mission statements, statements of values, and strategic action plans at top research-oriented US medical schools and US medical schools with a social mission. A Web search was performed to locate three documents for each medical school: the mission statement; a statement of values; and a strategic plan. Data were retrieved on the number of underrepresented minority graduates and total graduates from each school in the graduating classes of 2015–2019. The number and percentage of graduates during this period were compared according to schools’ mission statements using rank-sum tests. Other quantitative study data were compared by school mission using Fisher’s exact tests. Five of the schools with a social mission (25%) and none of the schools with a research mission had a mission statement that addressed increasing representation of underrepresented minority students in the medical school (p = 0.047). Schools with a mission statement that addressed this group had a higher proportion of those graduates during 2015–2019 (median 66%; IQR 28%, 68%) compared to schools that did not address this in their mission statement (median 10%; IQR 6%, 13%; p = 0.003). More research is needed to explore the association between US medical school mission statements and the representation of underrepresented students in medical education, especially at research-oriented medical schools.

Just in TIME: Trauma-Informed Medical Education

Numerous organizations implement a trauma-informed approach. This model assists institutions in providing care and education that delivers support to members who have undergone traumatic experiences, and many institutions apply the principles as a universal precaution. Student and trainee experiences in medical education reveal a hidden curriculum that may deliver conflicting messages about the values of an institution, in which equity is promoted, but biased and discriminatory practices are commonplace. Implicit racial bias has been identified in the patient-provider interaction and may also extend its impact on the learner experience. Bias and discrimination inflict trauma on its targets via emotional injury. Applying the principles of the trauma-informed approach, we advocate for trauma-informed medical education (TIME). TIME fosters awareness that students and trainees can experience trauma from a biased system and culture and advocates for the establishment of policies and practices that support learners to prevent further re-traumatization. TIME will serve as a means to deliver just and equitable education.

Racial, Ethnic, and Gender Diversity in Pediatric Anesthesiology Fellowship and Anesthesiology Residency Programs in the United States: Small Reservoir, Leaky Pipeline

BACKGROUND

The critical question of racial and gender diversity in pediatric anesthesia training programs has not been previously explored. The primary objective of this study was to evaluate trends by race/ethnicity and gender in pediatric anesthesiology fellowship training programs in the United States for the years 2000 to 2018.

METHODS

Demographic data on pediatric anesthesiology fellows and anesthesiology residents were obtained from the self-reported data collected for the Journal of the American Medical Association's annual report on Graduate Medical Education for the years 2000 to 2018. Diversity was assessed by calculating the proportions of trainees per year by gender and racial/ethnic groups in pediatric anesthesiology fellowship and anesthesiology residency programs. Logistic regression equations were developed to estimate the annual growth rate of each racial/ethnic groups.

RESULTS

The number of pediatric anesthesiology fellows increased from 57 trainees in 2000-2001 to 202 in 2017-2018 at an average rate of 9 fellows per year (95% confidence interval [CI], 8-10). These increases were primarily due to white trainees (54.4%-63.4%) as the proportions of black (7.0%-4.5%), Asian (26.3%-21.3%), and other minority (12.3%-10.9%) trainees have remained low. The number of anesthesiology residents increased from 3950 trainees in 2000-2001 to 5940 in 2017-2018 at an average rate of 99 residents per year (95% CI, 88-111). Within all anesthesiology trainees, these increases were due to white trainees (55.7%-61.3%) as the proportion of black (5.0%-6.0%), Asian (25.8%-24.1%), and other minority trainees (8.2%-8.5%) has remained fairly constant over the time period. Despite the overall lower proportion of female anesthesiology residents (range: 27.0%-37.5%), a steady increase in the number of women in pediatric anesthesiology fellowship programs has reversed the gender imbalance in this population as of 2010.

CONCLUSIONS

While historic gains have been made in gender diversity in pediatric anesthesiology, there is persistent underrepresentation of black and Hispanic trainees in pediatric anesthesiology. It appears that their low numbers in anesthesiology residency programs (the reservoir) may be partly responsible. Efforts to increase ethnic/racial diversity in pediatric anesthesiology fellowship and anesthesiology residency training programs are urgently needed.

Projected Estimates of African American Medical Graduates of Closed Historically Black Medical Schools

IMPORTANCE

There continue to be low numbers of underrepresented minorities, including African Americans, in academic medicine. Historically Black medical colleges and universities are major sources of training for medical school graduates who are African American or who belong to other underrepresented minority groups. Several historically Black medical schools were closed during the period surrounding the 1910 Flexner report. The implications of these school closures with regard to the number of African American medical school graduates have not been fully examined.

OBJECTIVE

To examine the consequences associated with the closure of historically Black medical schools for the number of African American medical school graduates.

DESIGN, SETTING, AND PARTICIPANTS

This observational economic evaluation used steady expansion and rapid expansion models to estimate the consequences associated with the closure of historically Black medical schools for the number of African American medical school graduates. The numbers of graduates from 13 historically Black medical schools that are now closed were obtained through historical records. Data on historically Black medical schools that are currently open were obtained from school-specific reports and reports published by the Association of American Medical Colleges. The study focused on projected estimates of outcomes from the hypothetical continued operation and expansion of 5 closed historically Black medical schools that were included in the Flexner report: Flint Medical College of New Orleans University, Knoxville Medical College, Leonard Medical School of Shaw University, Louisville National Medical College, and the University of West Tennessee College of Medicine and Surgery-Memphis.

MAIN OUTCOMES AND MEASURES

The main outcome was the estimate of the number of African American students who would have graduated from historically Black medical schools that were closed during the period surrounding the 1910 Flexner report.

RESULTS

Among the 5 historically Black medical schools that were closed, the estimated mean number of graduates per year was 5.27 students at Flint Medical College, 2.60 students at Knoxville Medical College, 11.06 students at Leonard Medical School, 4.17 students at Louisville National Medical College, and 6.74 students at the University of West Tennessee. If the 5 closed historically Black medical schools had remained open, the steady expansion and rapid expansion models indicated that these schools might have collectively provided training to an additional 27 773 graduates and 35 315 graduates, respectively, between their year of closure and 2019. In the analysis of Leonard Medical School and the University of West Tennessee only, the steady expansion and rapid expansion models indicated that these 2 schools would have provided training to an additional 10 587 graduates and 13 403 graduates, respectively, between their year of closure and 2019. An extrapolation based on the racial and ethnic self-identification of current graduates of historically Black medical schools indicated that if these closed schools had remained open, the number of graduating African American physicians might have increased by 355 individuals (29%) in 2019 alone.

CONCLUSIONS AND RELEVANCE

To increase the number of African American medical school graduates, consideration should be given to creating medical education programs at historically Black colleges and universities. Such programs may start with small enrollment but could have positive consequences for the diversity of the physician workforce.

An Evaluation of Race Disparities in Academic Plastic Surgery

BACKGROUND

Academic plastic surgery has a history of underrepresentation of ethnic and racial minority groups. Recent policy shifts by national medical groups and plastic surgery societies have focused on reversing these inequalities. This study seeks to measure ethnic and racial representation at academic and leadership positions following recent changes.

METHODS

A cross-sectional study was conducted in June of 2018, measuring ethnic and racial diversity of U.S. academic plastic surgery faculty. Among faculty, career qualifications, years of experience, faculty positions, and leadership ethnicity were compared.

RESULTS

A total of 930 academic plastic surgeons were included in the study. Classified collectively as nonwhite, this group graduated more recently than other academic plastic surgeons (2006 versus 2001; p < 0.0001) and had greater rates of clinical fellowship attainment (OR, 1.62; 95 percent CI, 1.16 to 2.26). Nonwhite individuals were less likely to be employed in the full professor position compared with their white colleagues (OR, 0.6; 95 percent CI, 0.42 to 0.88; p = 0.0077). However, after adjustment for differences in years of postresidency experience, this disparity was no longer significant (OR, 1.06; 95 percent CI, 0.62 to 1.83; p = 0.82), indicating the importance of current cohort experience differences. Assessment of program leadership found that nonwhite chairs employed significantly more nonwhite faculty (42.5 percent versus 20.9 percent; p < 0.0001).

CONCLUSIONS

Academic plastic surgery continues to face disparities in representation of both ethnic and racial minorities. Current inequalities are most severe at senior academic positions and may be linked to cohort experience differences along with leadership and promotion biases.

Racial disproportionality of students in United States colleges of pharmacy

OBJECTIVE

To describe the disproportionality of racial and ethnic people of color (i.e., minorities) among the student body in schools and colleges of pharmacy (COPs) compared to county-specific United States Census Bureau data.

METHODS

Data were obtained from national databases and published reports from the American Association of Colleges of Pharmacy. In addition, demographic information for enrollees of minority-serving institutions and predominantly white institutions was obtained and racial disproportionality was assessed to determine the degree of concordance between enrollees and the demographics of people within the county that the school was located. Data were evaluated using descriptive statistics.

RESULTS

Compared to the general population in counties where COPs are located, Asians are over-represented while all other students of color are underrepresented. The top schools that have a negative disproportionality rate for Black students included Thomas Jefferson University (-40.49), Wayne State University (-40.13), Philadelphia College of Pharmacy (-39.90), and the University of Tennessee (-39.74).The top five schools that have a negative disproportionality rate of Hispanic students included Loma Linda University (-45.67), California Health Sciences (-45.64), the University of Southern California (-43.79), the University of the Pacific California (-37.95), and Texas Southern University (-36.65). The enrollments within most COPs do not reflect the racial and ethnic diversity of the counties in which they are located.

CONCLUSIONS

To meet the healthcare needs of an increasingly diverse population, each institution should establish a strategic plan for increasing diversity and evaluating and adopting best practices.

Efforts of diversity and inclusion, cultural competency, and equity in the genetic counseling profession: A snapshot and reflection

Like its peer health professions, the genetic counseling field recognizes the need for and value of diversity, inclusion, cultural competency, and equity (DICE). However, despite decades of diversity initiatives, minimal gains in the percentage of genetic counselors with minority identities have been realized. In order to gather information about DICE efforts, two surveys were created and distributed to genetic service providers, trainees, and genetic counseling program faculty yielding a total of 76 responses. Additionally, a literature scan was performed to gain an understanding of past and ongoing DICE efforts in the career. Three emerging domains resulted from quantitative and qualitative analysis of the submitted data: (1) Categories of DICE Projects, (2) Parties Carrying Out DICE Projects, and (3) What is Missing? Overall, inclusion efforts are notably underrepresented among DICE projects. Also, DICE efforts are generally under-supported, unfunded, and under-recognized as work-related responsibilities. To enhance DICE within the genetic counseling profession, we recommend developing additional research and projects focused on career inclusion and equity, implementing policies requiring DICE training for leaders within the field, encouraging project evaluation and outcomes dissemination, and creating a well-maintained web-based centralized repository for DICE resources.

Releasing the Net to Promote Minority Faculty Success in Academic Medicine

Underrepresented minority faculty in academic medicine continue to be underrepresented in academic health centers across the country. Their underrepresentation impacts advancements in clinical care, education, and discovery and slows our forward progress in the field. Underrepresented in medicine faculty includes people who are black or African American, Hispanic or Latinx, or Native American. Barriers to underrepresented faculty recruitment, retention, and advancement include minority and gratitude taxes, imposter syndrome, and a lack of an appreciation of power distance and distance traveled. This article reviews five barriers to progress in achieving appropriate diversity among faculty and leadership of academic health centers, focusing on the multiplying effects of these barriers and potential steps forward.

Preparing the Next Generation of Diverse Biomedical Researchers: The University of North Texas Health Science Center's Initiative for Maximizing Student Development (IMSD) Predoctoral Program

The National Science Foundation (NSF) reports that underrepresented minority students are just as interested as their White counterparts in majoring in science upon entering college.1 However, the numbers of those receiving bachelors' degrees, attending graduate school, and earning doctorates remain lower than their White peers. To close this gap, the National Institutes of General Medical Science's (NIGMS) Initiative for Maximizing Student Development (IMSD) at University of Texas Health Science Center (UNTHSC) supports the timely completion of PhD degrees by underrepresented students and their transition into successful biomedical research careers. Throughout UNTHSC's IMSD training program, we have designed interventions anchored by the central hypothesis that PhD attainment requires attentiveness to multiple factors (knowledge, psychosocial, financial and self-efficacy). An assessment of program outcomes demonstrates a progressive increase in trainee retention. Importantly, not-withstanding quantitative measurable outcomes, trainee and mentor evaluations express the value in addressing multiple factors relevant to their success. Since 1996, our cumulative success of underrepresented minority students completing the doctorate increased from 64% (1996) to 84% completion (2018). Herein, we describe the UNTHSC IMSD training approach spanning its performance over two five-year cycles (2004-2008; 2009-2013) and new interventions created from lessons learned that influenced UNTHSC's newly awarded IMSD program (2017-2022).

The "Race" Toward Diversity, Inclusion, and Equity in Pathology: The Johns Hopkins Experience

With 3.8% black trainees in 2012, pathology had significantly fewer trainees from groups underrepresented in medicine compared to other specialties. To address this, faculty in the Johns Hopkins Department of Pathology established an outreach program and funded rotation for students underrepresented in medicine and from disadvantaged groups. The aims were to increase exposure to the field and improve diversity, inclusion, and equity in pathology. A 1-month rotation for students underrepresented in medicine was established in 2013. Rotation schedules tailored to each rotator's interests included resident conferences and individual faculty meetings. In 2016, a proactive outreach program was established. Faculty visited historically black medical schools and underrepresented in medicine student groups at other institutions, where they gave a "Careers in Pathology" presentation targeted to second- and third-year medical students. Faculty also attended underrepresented in medicine student conferences and participated in high school student programs to further expand the underrepresented in medicine pipeline into medicine and pathology. Since 2016, fourteen outreach presentations have been delivered. The number of rotators increased from 1 in 2013 to 18 in July 2019. Rotators self-identified as African, African American, Hispanic, and Native American. Most were second- to fourth-year medical students, and 1 was a pathology resident. Six rotators are currently pathology residents, and others are strongly considering applying to pathology. The outreach efforts account for the success of our rotation, which, in turn, has had a positive impact on interest in pathology. However, we recognize barriers to retention and intend to incorporate additional professional development activities to further address equity.

Health Equity and the Tripartite Mission: Moving From Academic Health Centers to Academic-Community Health Systems

Academic health centers (AHCs) play a significant role in educating the health care workforce, conducting innovative biomedical and clinical research, and delivering high-quality patient care. Much work remains, however, to adequately address the social determinants of health and equity that affect communities where patients live, work, and play. Doing so will help achieve the Quadruple Aim while addressing the unjust social structures that disproportionately impact communities of color and vulnerable populations. AHCs have a timely opportunity to focus their leading roles in education, research, and clinical care on social determinants, moving outside their walls to create academic-community health systems: a collection of academic-community partnerships advancing health equity through collaboration, power sharing, and cocreation.This Perspective proposes four strategies to start developing academic-community health systems. First, embark on all efforts through cocreation with communities. Second, address how future health care professionals are recruited. Third, build the right skills and opportunities for health care professionals to address health inequities. Finally, develop research agendas to evaluate programs addressing inequities. A fully realized vision of an academic-community health system will demonstrate interdependence between AHCs and the community. While considerable AHC resources are invested in building community capacity to improve health and health equity, health systems will also benefit in a multitude of ways, including increasing the diversity of ideas and experiences integrated into health systems. These strategies will support AHCs to embed across each arm of the tripartite mission a focus on partnering with communities to advance health equity together.

Quantitative and Qualitative Factors Associated with Social Isolation Among Graduate and Professional Health Science Students

Objective. To determine the prevalence of social isolation and associated factors in graduate and professional health science students. Methods. Quantitative and qualitative data were gathered via an online survey from graduate and professional students in the colleges of dentistry, medicine, nursing, pharmacy, and public health at a Midwestern university. Questions assessed students' demographics, weekly activity hours, support systems, and financial concerns, and included the 20-item UCLA Loneliness Scale. Logistic regression was performed using the binary outcome of feeling socially isolated (yes/no) and examined program-related respondent comments using thematic analysis. Results. There were 427 survey respondents with 398 completing the full survey. Students answering the social isolation question (n=386) were included in the regression analysis. Nearly one-fifth (19.4%) of respondents indicated social isolation, with the highest percentage among nursing respondents (40.7%). Lacking a strong support, being a non-native English speaker, having caregiving responsibilities, and experiencing "lonely" items described in the UCLA Loneliness Scale were positively associated with social isolation. The ability to discuss feelings with friends in their professional program and experiencing "non-lonely" items were negatively associated with social isolation. Ninety-six comments revealed nine risk factor themes in four categories: individual (feeling different from peers, personality, employment), interpersonal (competition/exclusionary atmosphere, faculty relationship), organization (too busy with coursework, isolating program) and community (relocation reduces social support). Student-involvement in organizations (activities encouraging socialization) and community (support from outside the group) were protective factors. Conclusion. Understanding associated factors and designing strategies to reduce student social isolation may enhance the quality and well-being of future health professionals and scientists.

An Institutional Coordinated Plan for Effective Partnerships to Achieve Health Equity and Biomedical Workforce Diversity

The rapid growth and accumulation of specialized knowledge in today's biomedical fields, combined with entrenched and emerging health issues that persist among certain groups within the US population, emphasizes the significant need to diversify the nation's biomedical science workforce. The under-representation of minorities in science results in inadequate scientific input from divergent social or cultural perspectives and detracts from our nation's ability to resolve health disparities. The University of North Texas Health Science Center at Fort Worth has developed a coordinated approach with local, regional, and national partners to increase participation of underrepresented students along the career pathway from K-12 to faculty level. Career stage specific activities that include research, mentoring, networking, career development, grantsmanship and health disparities curriculum are provided for participants. Successful outcomes from our coordinated plan includes an increase in participant self-efficacy, research presentation awards, increase in grant awards and publications, and career advancement. Through partnerships within our institution, local school districts, and minority serving institutions nationwide, our coordinated plan provides mutually beneficial co-learning experiences to increase the number of under-represented individuals entering translational research focused on increasing the biomedical research workforce diversity and achieving health equity.

The Health Care Institution, Population Health and Black Lives

The ongoing existence of institutionalized racism and discriminatory practices in various systems (education, criminal justice, housing, employment) serve as root causes of poor health in Blacks Lives. Furthermore, these unjust social structures and their complex interplay result in inefficient utilization of health services and reactive or futile interactions with medical providers. Collectively, these factors contribute to racial disparities in health and treatment represents a significant portion of the nation's health care expenditures. In order for health care systems to optimize population health goals, racism must be recognized as a determinant of health. As anchor institutions in their respective communities, we offer hospitals and health systems a conceptual framework to address the issue within internal and external constructs.